Running head

It’s No Joke: The State of the World’s Toilets 2015

WaterAid/Poulomi Basu Hanging latrines surrounded by rubbish in Madagascar. WaterAid/Anna Kari Introduction

We all laugh at toilet humour – but the state This is a problem that can be solved. of the world’s toilets is really no joke. In September, the UN adopted new Global For people in developed countries, flushing Goals on sustainable development. The entire a toilet and turning on a tap is taken for world has come together to agree a path to a granted. But more than 650 million people in fairer, more sustainable world – one in which the world do not have access to clean water, extreme poverty is eliminated and no matter and more than 2.3 billion do not have access where you are you have enough to eat, clean to a safe, private toilet.1 Diarrhoea is one water to drink, a safe, private place to relieve of the three most common killers of young yourself and soap and water to wash with. children globally, along with pneumonia and malaria.2 Most of these deaths – 58% of Goal 6 promises adequate, equitable access them – could be prevented by clean water, to water, sanitation and hygiene to everyone sanitation and good hygiene including everywhere by 2030. handwashing with soap.3 Now we need to work together to bring these That is more than 314,000 young children4 goals to fruition. who could be saved, every year. This report shows us where we need to start.

1 It’s No Joke: The State of the World’s Toilets 2015

The background: why your toilet is so important

Your toilet. You use it every morning without and hygiene are not in place, can be illustrated by thought, and the idea of trying to get by without an ‘F’ diagram: minute particles of faeces, which one is almost impossible to imagine. But doing get onto fingers, are spread by flies, picked up in without a toilet has many terrible, tragic costs fields, spread through fluids (including waterways) for communities. and then ingested, either directly or when a person eats contaminated food (see diagram below).6 In Not having a proper toilet, whether you defecate in addition, flies carrying faeces can land on faces, the open or use a bucket or rudimentary pit latrine spreading infections or blinding eye disease. which leaks its contents, means you have no way to prevent your faeces from contaminating your Contamination routes include water polluted by pit environment. This is a one-way street to illness – latrines or open defecation, food prepared in the one gram of faeces carries up to 1 million bacteria presence of faecal matter, poor or no handwashing and 10 million viruses.5 When faeces is let loose in after using the toilet or changing nappies, and poor your environment, minute amounts contaminate or no cleaning of anything that has been in contact your hands, food and water, and spread diseases. with faeces.

This faecal-oral transmission of disease, which This transmission has a far wider impact than many happens when the barriers of toilets, safe water people realise.

Fluids

Fields

Faeces Foods New host

Flies

Fingers

Source: UN Water http://esa.un.org/iys/docs/IYS%20Advocacy%20kit%20ENGLISH/Fact%20sheet%201.pdf

2 The background: why your toilet is so important

Source: World Health Organization/UNICEF

• Maternal health After the first week of life, sepsis is the most common cause of death of babies up to one Every day, 800 women around the world die of month old. preventable causes associated with pregnancy and childbirth.7 Of these deaths, 99% are in developing countries, and more than 10% are • Child health caused by sepsis, a condition which arises when Children younger than five years are more the body cannot cope with severe infection. susceptible to infections when growing up in a place with dirty water and poor sanitation In South Asia, nearly 14% of maternal deaths than are older children, and the impacts follow can be attributed to sepsis.8 Many of these them well beyond early childhood. If children deaths are preventable. If women can give birth live in a community without toilets, the areas in in clean, hygienic surroundings, and their which they play and live are contaminated by babies are delivered by skilled attendants who human waste. This is very easily spread to their have been able to wash their hands with soap hands and food, and into their bodies. and sterilise their instruments, the likelihood of infection is greatly reduced. Yet results of a Preventable diarrhoeal illnesses linked to World Health Organization (WHO) survey of low- dirty water and poor sanitation kill more than income and middle-income countries showed 314,000 children under five every year.11 that 38% of health-care facilities do not have Many hundreds of thousands more are left even basic access to water, 19% do not have stunted, their physical, cognitive and social basic sanitation and 35% do not have water and development impaired by malnutrition (by which soap for handwashing.9 in this report we mean undernutrition – the under-absorption of nutrients). • Newborn mortality The first few weeks of a baby’s life are when they Malnutrition doesn’t just occur when there isn’t are most vulnerable, especially when they are in enough food – repeated infections and diarrhoea an environment with dirty water, poor sanitation make it difficult for a child’s small body to and inadequate hygiene. The environment in absorb nutrients. which babies are born has an important impact on whether the bacteria that cause sepsis are Studies show that stunting is more common in spread, before, during and after delivery. places with high rates of open defecation, because faecal matter contaminates the food, In Sub-Saharan Africa and South Asia in 2013, water and general environment, making sepsis, meningitis and tetanus – all infections children frequently ill, and can permanently that are linked to unhygienic environments – damage children’s intestines and thereby their killed more than 400,000 newborn babies.10 ability to absorb nutrients.

3 It’s No Joke: The State of the World’s Toilets 2015

The implications reach for their students.12 beyond health. The impact of inadequate toilets at school is greater on girls who have begun menstruation. Without proper sanitary supplies or a safe, • Gender equality private place at school to wash and care for It is women and girls who feel the impact of a themselves, many girls stay home for that week lack of sanitation most severely. Without a safe, each month; they quickly fall behind, and it’s private place to relieve themselves, girls and often not long before they stop attending entirely. women are often left with no choice but to go out at daybreak or in the evening to find a place • Economic development to go in a field, roadway, railway track or bush. The cost of hospital beds full of people suffering These unhygienic, unsafe conditions can from preventable illnesses linked to dirty water contribute to infection and leave them more and poor sanitation holds back a country’s vulnerable to harassment or assault. workforce and its economic development. The annual global economic losses associated How girls and women care for themselves during with inadequate water supply and sanitation their periods is also of major concern – not just are estimated to be US$260 billion.13 for the risk of infection but for the lack of dignity a woman experiences when she does not have This is nearly double the net overseas a safe, private place to manage her periods. development aid – $135.2 billion – given by donor nations in 2014.14 • Education Imagine if your primary school had no toilets in Keeping communities healthy increases working condition, or if there were just one or productivity and opportunity. Investing in water two in a school of 600 or more students. This is and sanitation systems has tremendous the reality for too many primary schools in economic rewards – at least $6 return on every developing countries, and it has a serious $1 spent on eliminating open defecation, and impact on how long students are able to stay in $3 for every $1 spent on sanitation.15 education. Children who are frequently off sick because of infections picked up in unhygienic Unfortunately, for many countries there is still schools are more likely to fall behind and drop a long way to go before the vision of a safe, out. UNICEF found that in low-income countries private toilet for every household will become only 46% of schools, on average, have toilets a reality.

A pit latrine in poor repair in rural Niger. 4WaterAid Niger Part 1: The ten worst places in the world to find a toilet

Part 1: The ten worst places in the world to find a toilet Bottom ranked: South Sudan Runners up: Niger, Togo, Madagascar

Rank Country % of Gross Average life Maternal Child % of population national expectancy, mortality deaths, children without income at birth18 rate, sepsis- under stunted access to per capita (2013) related (per five, from (indicator of an ‘improved’ ($)(2014)17 100,000 diarrhoea malnutrition)21 toilet births)19 (per 1,000; (2015)16 2013)20

11 South Sudan 93.3 940 55 75.2 9.8 31

12 Niger 89.1 420 58 64.9 11.8 44

13 Togo 88.4 570 56 46.4 7.1 28

14 Madagascar 88.0 440 65 45.3 5.2 49

15 Chad 87.9 980 51 100.1 17.9 39

16 Sierra Leone 86.7 710 46 113.3 21.4 38

17 Ghana 85.1 1,600 61 39.1 6.0 19

18 Congo 85.0 2,710 59 42.2 2.5 25

19 Tanzania 84.4 930 61 42.2 3.8 35

10 Eritrea 84.3 680 63 39.1 5.1 50

Ibrahim Soumana, 15, a sixth- grader, in front of a WaterAid school latrine in the village of Sinder in the Tillaberi Region Ibrahimof Niger. “We Soumana, students no longer 15, a sixth-grader, in front of a WaterAid school latrinehave to leave in the the school village and go of Sinder in the Tillaberi Region of Niger. into the bush to relieve ourselves, now‘We that students the latrine has no been longer built.” have to leave the school and go into the

bush to relieve ourselves, now that the latrine hasWaterAid/Nyani been Quarmyne/Panosbuilt.’ WaterAid/Nyani Quarmyne/Panos

5 It’s No Joke: The State of the World’s Toilets 2015

Africa’s newest country, South Sudan, holds the rudimentary toilets, so open defecation, which dubious title of being the hardest place in the spreads disease, is common. In fast-growing urban world to find a household toilet. areas, natural sources of water are drying up, and there is little sanitation infrastructure. South Sudan gained independence in July 2011, part of a 2005 peace agreement which ended a Rounding out the bottom four are Togo and long civil war, but has since been beset by power Madagascar. The latter – a large island off southern struggles and violence. Amid such unrest, Africa – is among the world’s poorest countries, rebuilding is a slow and complicated road; more with more than 75% of its people living in 22 than 50% of South Sudan’s people live below poverty,25 and 88% lacking access to basic toilets. the national poverty line,23 and 91% are without basic, safe sanitation, contributing to high levels Finally, we include a mention for Papua New of maternal and child mortality.24 Guinea, which is the only state outside Sub- Running a close second to South Sudan is Niger. Saharan Africa to fall in the world’s hardest 12 This landlocked desert country has seen huge countries in which to find a toilet, by percentage upheaval and conflict; a decade of internal conflict of population. Some 81% of this Pacific island’s left more than 100,000 people displaced. 41% of residents do not have a safe, private toilet to use. its population lives in extreme poverty and 89.1% With an average per-person gross national income does not have safe, private toilets. of $2,030, a child mortality rate of 61 per 1,000 livebirths and a life expectancy of 62 years, life for Much of Niger’s population is nomadic, which people here is incredibly difficult. On average 220 poses particular challenges to access to water and women out of every 100,000 will die in childbirth, toilets. Distances to water sources are great, and and at least one in 20 of those will die of sepsis water supplies are often polluted with naturally which might have been prevented by safe water, occurring arsenic. Populations which move on good sanitation and rigorous hygiene, including regularly are unlikely to build more than the most by the midwife washing their hands with soap.

Stilt toilet over the beach, Barakau, Papua New Guinea. WaterAid/Tom Greenwood

6 Part 2: Top ten places with the longest queues for toilets

Part 2: Top ten places with the longest queues for toilets Longest queue: India Runner up: China

Rank Country Number of Gross Average life Maternal Child % of people without national expectancy, mortality rate deaths, children access to income per at birth due to sepsis under 5s, stunted ‘improved’ capita ($) (2013)28 (per 100,000 from (indicator of private toilets (2014)27 births)29 diarrhoea malnutrition)31 (2015)26 (per 1,000; 2013)30

11 India 774,222,300 1,570 66 26.0 5.5 39

12 China 329,851,200 7,380 75 0.8 0.5 9

13 Nigeria 130,387,500 2,970 52 57.7 11.0 33

14 Indonesia 100,168,400 3,630 71 10.4 1.6 36

15 Ethiopia 71,217,200 550 64 43.3 6.0 40

16 Pakistan 68,666,800 1,410 67 23.3 9.0 45

17 Bangladesh 63,267,800 1,080 71 23.3 2.6 36

18 Democratic 50,833,300 380 50 75.2 12.3 43 Republic of the Congo

19 Tanzania 44,159,400 930 61 42.2 3.8 35

10 Russian 39,468,700 13,210 71 1.1 0.1 No data Federation

India, the world’s second most populous nation, assuming each person needs about four minutes in has a well-known problem with sanitation. Cities the toilet. growing at an incredible pace with unofficial, unserviced slums, combined with cultural The resulting health crisis is a serious matter. More preferences for open defecation in fields rather than 140,000 children younger than five years die than enclosed spaces, mean India has the World’s each year in India from diarrhoea.32 Nearly 40% of Longest Queues for Toilets. India’s children are stunted; this will affect both their life chances and the future prosperity of India. If you stretched all 774 million people in India now India also has high rates of maternal and newborn waiting for household toilets, the queue would mortality linked to sepsis. The equipment stretch from Earth to the moon – and beyond! necessary to prevent infection during and after That queue would take 5,892 years to work through, childbirth is simple and inexpensive, but requires

7 It’s No Joke: The State of the World’s Toilets 2015

clean water and soap, and clean surroundings, by 2019 and to educate people about the long-term which are difficult to achieve in an environment health and economic benefits of using a toilet. contaminated by open defecation, and without good hygiene practices such as handwashing with soap This is an important and long-overdue initiative, by clinic staff and midwives. and is bringing change to India’s communities. But simply building the toilets won’t be enough. What Work is underway in India to end the crisis. Prime will be absolutely crucial is getting local, state and Minister Narendra Modi has given the issue high national government to make this a priority, and political priority, and in autumn 2014 announced creating the cultural shift that will ensure that once the Swachh Bharat (Clean India) Mission. Swachh the toilets are built they are used – by everyone. Bharat aims to ensure every household has a toilet

0 “My name is Tahira Devi. I’m 40 years old The toilets are also dirty and not well and live in Soniya Camp in East Delhi. maintained. If I had my own toilet in my I’m a local leader and work to improve the own house it would be very good, especially water, sanitation and hygiene facilities if it is connected to a sewer line. This would facilities in my slum. There are many problems help my son and daughter to not depend because of the community toilet. There is on the community toilet and to study too much rush as too many people are better. Having my own toilet would also dependent on it. People don’t pay for its help in preventing illness and help my proper maintenance. In the morning, when we family lead a healthy life and contribute to have to work, we waste time standing in line. our economic betterment.”

Tahira Devi, 40, in the community toilet block in the Soniya Camp slum east of Delhi, India. WaterAid/Anil Cherukupalli

8 Part 2: Top ten places with the longest queues for toilets

0

WaterAid/Poulomi Basu

Sarita, 24, at home in Juhi Bamburahiya, “I don’t get water every day; somebody will Kanpur, India. Sarita suffered from polio as help me get water from the drum. People are a child and now cannot walk. Her husband nice to me and help me out. The water from works in a factory in Delhi. WaterAid partner the drum isn’t clean – I just use that for Shramik Bharti built the household toilet she cleaning and cooking. I pay my neighbour shares with two families. 150 rupees every month and they give me drinking water from their own water source. “I crawl to the toilet. It’s a normal squat No one will collect water from the handpump toilet as I can squat…I used to live with my for me as it’s too far away. husband’s relatives who had a toilet, but they didn’t want us to live there. So I spoke “I would like a tap so it would be easy for me. to (WaterAid partner) Shramik Bharti and I would also like the area to be cleaner and they helped us get a toilet near this home tidier. Every evening I clean the whole area but so I could move out. by the morning, it is dirty again. There’s just so much rubbish. People burn the rubbish.”

9 It’s No Joke: The State of the World’s Toilets 2015

Part 3: Most people defecating in the open, per square km Worst offender: India Runners up: Haiti, Togo

Rank Country Number Surface Average Average Maternal Child % of practising area number of life mortality deaths, children open (sq. km)34 people expectancy, rate due to under 5s, stunted defecation practising at birth sepsis (per from (indicator (2015)33 open (2013)36 100,000 diarrhoea of mal- defecation per births)37 (per 1,000; nutrition )39 sq. km35 2013)38

11 India 569,397,200 3,287,260 173 66 26.0 5.5 39

12 Haiti 2,011,100 27,750 72 63 31.5 8.7 22

13 Togo 3,710,000 56,790 65 56 46.3 7.1 28

14 Nepal 8,973,700 147,180 61 68 26.0 2.8 37

15 Benin 5,800,200 114,760 51 59 35.0 7.7 34

16 Nigeria 46,017,300 923,770 50 52 57.7 11.0 33

17 Cambodia 7,439,800 181,040 41 72 9.3 2.8 32

18 Burkina Faso 9,876,500 274,220 36 56 41.2 9.6 33

19 Pakistan 25,100,200 796,100 32 67 23.3 9.0 45

10 Indonesia 52,252,400 1,910,930 27 71 10.4 1.6 36

India takes the title in this category, with 173 in the Square Mile of the City of London, or 15,000 people defecating in the open for every square people in Manhattan, New York City. Open kilometre in the country. That ratio would be the defecation leaves communities filthy and children same as 500 people having to defecate in the open ill and undernourished.

10 Part 3: Most people defecating in the open, per square km

India’s ‘Swachh Bharat’ (Clean India) mission

In October 2014, Indian Prime Minister a focus on changing people’s behaviour to Narendra Modi announced his ‘Clean India’ ensure everyone uses these new toilets will mission to deliver a toilet to every household be required. If just one person continues to and end open defecation by 2019. This is no defecate in the open, the environment small task in a country where 560 million remains polluted for everyone. people still defecate in the open. If Clean India is to succeed, sanitation must One year in, they’ve delivered toilets to be seen as a fundamental human right along 8 million households – a promising start. with food, education, livelihoods and health, But, to succeed, more funding, greater for everyone in the country – including the government prioritisation at all levels and poorest and most marginalised.

An open defecation area opposite Deepak Colony, east of Delhi, India. WaterAid/Anil Cherukupalli

11 It’s No Joke: The State of the World’s Toilets 2015

Part 4: Worst of the best: toilet problems in developed countries Worst toilet access of developed countries: Russia Runners up: Moldova, Romania Dishonourable mentions: Ireland, UK, Sweden

Rank Country % of Number of Gross Average Maternal Child deaths, population people national life mortality rate under without without safe, income per expectancy, due to sepsis five, from safe, private private capita ($) at birth (per 100,000 diarrhoea toilets toilets (2014)42 (2013)43 births)44 (per 1,000; (2015)40 (2015)41 2013)45

11 Russian 27.8 39,468,700 13,210 71 1.1 0.1 Federation

12 Republic of 23.6 810,200 2,550 69 1.0 0.2 Moldova

13 Romania 20.9 4,515,100 9,370 74 1.5 0.1

14 Bulgaria 14.0 997,000 7,420 74 0.2 0.1

15 Latvia 12.2 248,000 15,660 74 0.6 0

16 Ireland 9.5 449,900 44,660 81 0.4 0

17 FYRO Macedonia 9.1 191,700 5,150 75 0.3 0.1

18 Lithuania 7.6 228,000 15,380 74 0.5 0

19 Albania 6.8 216,300 4,460 78 1.0 0.1

10 Belarus 5.7 525,600 7,340 72 0 0

UK 0.8 504,100 42,690 81 0.4 0

USA 0 36,100 55,200 79 1.3 0.1

Canada 0.2 65,200 51,690 81 0.5 0

Sweden 0.7 67,200 61,600 82 0.2 0

Japan 0 0 42,000 83 0.3 0.1

Australia 0 0 64,680 82 0.3 0

12 Part 4: Worst of the best: toilet problems in developed countries

Only 17 countries in the world – including Australia, many aboriginal communities.47 Japan, South Korea, Singapore and Saudi Arabia – have reported that just about every single What is harder to capture in statistics is the household in the country has a safe, private toilet.46 number of people who struggle even to access decent shared toilets – e.g. those sleeping on the Perhaps surprisingly, the USA, Canada, the UK and streets of big cities, or in camps for refugees and Sweden are not among them. The numbers without migrants, official and makeshift, which have toilets are somewhat larger in Russia and across sprung up across Europe to house people fleeing Eastern Europe. poverty or conflict.

Although the proportions are small compared In any place where access to sanitation is a with those in developing countries, all of these challenge, women, children, older people and nations have measurable numbers of people who disabled people are most likely to suffer most. live without private access to toilets in their For women and girls, managing menstrual hygiene households. This includes student dormitories, becomes a constant struggle, from lack of both bedsits and homeless shelters, as well as the toilets and affordable sanitary materials. apartment blocks once common in Eastern Europe, where more than one household might share a toilet. The UN’s new Global Goals call for access to water, sanitation and hygiene for everyone everywhere, In Canada, 65,200 rural residents lack private and for elimination of inequalities. In developed access to toilets in their homes – in part reflecting countries where these services are not delivered, the poor state of infrastructure and housing in it’s a question of political priority.

Disused privy in the back yard of 68 Dean Street, London, shot as part of WaterAid’s Great British Stink exhibition showing the history of sanitation in the UK. WaterAid/Thomas Bell

13 It’s No Joke: The State of the World’s Toilets 2015

Part 5: Most improved in access to sanitation, 1990–2015 Most improved: Tokelau Runners up: Vietnam, Nepal

Rank Country Improvement, Number of Number of Gross Average Maternal Child % of (% points), in people people national life mortality deaths, children population without without income expectancy, rate, from under 5, stunted living without sanitation, sanitation per at birth sepsis (per from (indicator of toilets, 1990 1990 (and (2015) (and capita (2013)52 100,000 diarrhoea malnutrition) vs 201548 %)49 %)50 ($) births)53 (per 55 (2014)51 100,000; 2013)54 11 Tokelau 900 100 No data No data No data No data No data 45.3 (54.8%) (9.5%) 1 12 Vietnam 43,945,800 20,555,200 1,890 76 2.7 2.9 19 41.8 (63.8%) (22%)

13 Nepal 17,297,200 15,416,800 730 68 26.0 2.8 37 41.3 (95.5%) (54.2%)

14 Pakistan 84,790,300 68,666,800 1,410 67 23.3 9.0 45 39.8 (76.3%) (36.5%)

15 Cambodia 8,791,600 9,025,400 1,020 72 9.3 2.8 32 39.5 (97.1%) (57.6%)

16 Micronesia 77,600 44,800 3,270 69 4.8 2.8 No data 37.7 (80.6%) (42.9%)

17 Paraguay 2,025,500 801,900 4,380 72 9.1 1.2 No data 36.3 (47.7%) (11.4%)

18 Honduras 2,541,000 1,461,800 2,280 74 10.0 1.4 No data 34.5 (51.8%) (17.3%)

19 Fiji 314,500 79,300 4,540 70 2.9 1.1 No data 34.3 (43.2%) (8.9%)

10 Bhutan 434,300 385,100 2,390 68 16.4 2.6 No data 31.5 (81.1%) (49.6%)

The two countries which have made the biggest Nearly matching Vietnam’s impressive progress is strides in sanitation are the tiny Pacific island Nepal. This mountainous, landlocked nation has nation of Tokelau (population 1,400), a territory made incredible strides in both water and of New Zealand that now enjoys more than 90% sanitation in recent years. Like neighbouring sanitation coverage, and Vietnam, which has now India, this isn’t just a problem of infrastructure. reached nearly 80% of people with sanitation and Delivering sanitation in Nepal also means has become one of Southeast Asia’s fastest- overcoming traditional cultural beliefs that it’s growing economies. better to defecate away from your home.

14 Part 5: Most improved in access to sanitation, 1990-2015

Public campaigns against open defecation in Nepal status in jeopardy and fears of waterborne illness have proven successful – communities have including cholera grew. celebrated their ‘Open Defecation Free’ status like weddings, with proud banners, music and food. There is much rebuilding still to do in Nepal, and water supply and sanitation repair will play a However, this progress was delivered a difficult crucial part. The importance of having access to blow by devastating earthquakes in April and May clean water and a safe, private toilet came into 2015 which killed more than 8,000 people and sharp relief in the days immediately after the levelled entire villages. earthquakes. These simple necessities can make all the difference for families trying to survive the The damage has set back many villages which initial days of shock and fear – the difference previously showed good progress on access to between being able to drink, cook, bathe and water and toilets. Villages that had celebrated their relieve yourself privately with a measure of good Open Defecation Free declarations found that hygiene, or falling ill and suffering even more.

Sarmila and her family, including her young son, stayed in a tent on their farm for a month after the earthquake, but continued to use their old toilet which was hard to reach and damaged by the earthquake. Eventually they were able to build a temporary shelter of wood and corrugated metal, and approached WaterAid Nepal’s local partner CIUD for help to build a safe temporary toilet.

“I cannot explain that it is such a great relief to get a toilet in our temporary shelter. It is very comfortable these days. The toilet in the shelter has saved lots of my time – now I do not have to worry about taking my son to the toilet.

“A toilet is very essential in our life. If there is no toilet we would be unhealthy and surroundings will be very dirty. This is because when there is no toilet, people will defecate in an open area, which is very risky for our Sarmila Shrestha, 26, at the toilet. health. It directly pollutes the river Ugrachandi Nala 2, Kavre, Nepal. and other water sources and when we WaterAid/Mani Karmacharya consume such contaminated water we would definitely get sick.”

15 Running head

A little-used household toilet in Panna district, Madhya Pradesh, India, used as a satellite dish stand. Poor construction and the failure to convince people to change their behaviour can lead to toilets falling into disuse. 16WaterAid/Andrés Hueso Part 6: Most behind on access to sanitation

Part 6: Most behind on access to sanitation Most behind on access to sanitation: Djibouti Runners up: Georgia, Nigeria

Rank Country Increase Number of Number of Gross Average Maternal Child % of (% points) in people people national life mortality deaths, children population without without income expectancy, rate due to under 5, stunted without access to access to per at birth sepsis (per from (indicator of toilets, 2015 sanitation sanitation capita (2013)60 100,000 diarrhoea malnutrition) vs 199056 (and %), (and %) ($) births)61 (per 63 201557 1990 58 (2014)59 100,000; (worst in world) 2013)62 11 Djibouti 18.7 472,900 199,800 No data 62 23.7 6.3 34 (52.6%) (33.9%)

12 Georgia 11.5 591,600 120,600 3,720 74 3.5 0.1 No data (13.7%) (2.2%)

13 Nigeria 9.1 130,387,500 59,206,600 2,970 52 57.7 11.0 33 (71.0%) (61.9%)

14 Tonga 3.4 9,600 5,400 4,290 73 6.0 0.2 No data (9.0%) (5.6%)

15 Zimbabwe 3.1 9,504,400 6,290,600 830 60 48.4 7.7 28 (63.2%) (60.1%)

16 Qatar 1.9 46,600 600 94,410 79 0.3 0 No data (2.0%) (0.1%)

17 Papua 1.3 6,187,500 3,319,400 2,030 62 11.0 5.4 50 New (81.1%) (79.8%) Guinea 1

18 Samoa 1.2 16,400 11,800 4,050 73 2.9 0.6 No data (8.5%) (7.3%)

19 Aruba 0.9 2,400 900 No data 75 No data No data No data (2.3%) (1.4%)

10 Belarus 0.8 525,600 504,700 7,340 72 0 0 No data (5.7%) (4.9%)

17 It’s No Joke: The State of the World’s Toilets 2015

In the unfortunate position of the world’s most regressive country on sanitation is Djibouti, a tiny What’s next? country bordering Ethiopia, Eritrea and Somalia. Racked by civil war until 2000, nearly a quarter of Access to water, sanitation and hygiene is a basic its population lives in extreme poverty. It has few human right. These services are essential for good natural resources, little arable land and little health, for progress in gender equality, for rainfall; its main income comes from its position economic development and for our dignity as at the southern entrance to the Red Sea, which human beings. makes it Ethiopia’s main trade route. Yet, whether you are a child growing up in rural In second position is Georgia. This former Soviet India, a homeless person in London, a refugee republic saw war with Russia in 2008 which fleeing conflict or a young woman giving birth in destroyed infrastructure and brought its economy Mali, the inability to access safe, private toilets to a standstill. Although now recovering, the has humiliating and sometimes devastating damage is still felt. Although country-wide access consequences. to sanitation is 86.3%, this is a decrease from 97.8% in the early 1990s. Whether you’re at home, at school or in a medical clinic, you have the right to a safe, private place to The third nation on this list is Sub-Saharan Africa’s relieve yourself. largest economy and now classed as a lower- middle-income country. Despite this, Nigeria is This year all UN member states have adopted new failing when it comes to progress on delivering Global Goals on sustainable development. This sanitation to its citizens. Some 71% of Nigeria’s 15-year framework aims to eradicate extreme people do not have access to basic, safe toilets; poverty and tackle inequalities and climate change more worrying, the number of households with by 2030, creating a world that is healthier, fairer access to sanitation has actually slipped by nine and more sustainable. percentage points since 1990. Goal 6 aims to deliver access to water, sanitation This takes a heavy toll on Nigeria’s people. An and hygiene for everyone everywhere. Without estimated 11 children in every 1,000 die of diarrhoeal achieving this goal, the world cannot achieve many illnesses each year in Nigeria, and 58 out of of the other goals – it can’t end hunger and 100,000 births result in the mother dying of sepsis. malnutrition, or ensure gender equality, education and healthy lives for all. Ultimately, it can’t deliver To change this situation will take political on the overarching aim – a world free from extreme commitment and financing from the very top. poverty by 2030. So it’s a big ask. But it can Nigeria needs to measure up to its status as happen, because it has happened before. In the a middle-income country and finance its UK, in Europe, in South Korea, in Singapore, and in infrastructure accordingly. This means mobilising many other countries, strong leadership, political domestic resources, including through taxes and will and sufficient funding for sanitation have tariffs, and making effective use of traditional aid dramatically changed public health and to target poor people. modernised societies.

Another obstacle to improving sanitation practices To get there we need determination and in Nigeria, including the use of toilets, is convincing commitment. We need to hold world leaders people to embrace their use. In some rural areas, to account and make them deliver on their people might prefer to find a spot in a field rather promises to reach everyone including the poorest, than use a small, possibly smelly room in their home. most vulnerable and most marginalised people in Promoting the health benefit of sanitation is key. our world.

18 Part 6: Most behind on access to sanitation

Kadoon Tilenen, 21, is a farmer in Agaku, Benue AppendixAt night, I am afraid so I don’t 1 go very– far from state, Nigeria. She is married with a small child the house. There are thorns that prick, and and another on the way. This is their accesssticks that injure me. to Defecating in the bush community’s pit latrine; she and her large disgusts me and makes me vomit a lot, extended family use the field to relieve especially in my pregnant state. themselves when the toilet is not sufficient for sanitation, sub- “Clean water and a toilet will make people all of them. no longer fall sick. The environment will “I use the latrine we have at home but I also saharanbe clean and we won’t see Africa, shit in the open. defecate in the bush if there is someone in the It will also help us save money and not spend toilet and I am pressed. The family is large so highestit on hospital bills. I think to people lowest would use one or two toilets will not serve. Countrylatrines if they %had of them. population without access (2015) “It feels very uncomfortable but sometimes Seychelles“The traditions 1.6I know is that it is not good I have no choice. In my condition, my stomach Réunionto see shit in the 1.7 open but these days it hurts me sometimes when I am in the bush Mauritiusdoesn’t really matter 6.8 because people have bending and the grasses help to cover. Equatorialto pass out Guinea faeces.” 25.5 Cape Verde 27.8 South Africa 33.6 Botswana 36.6 Rwanda 38.3 Gambia 41.1 Swaziland 42.5 Angola 48.4 Burundi 52.0 Senegal 52.4 Djibouti 52.6 Cameroon 54.2 Zambia56.1 Gabon 58.1 Malawi 59.0 Mauritania 60.0 Zimbabwe 63.2 Comoros 64.2 Sao Tome and Principe 65.3 Namibia 65.6 Lesotho 69.7 Kenya 69.9 Nigeria 71.0 Democratic Republic of the Congo 71.3 Ethiopia 72.0 Mali 75.3 Côte d’Ivoire 77.5 Central African Republic 78.2 Kadoon Tilenen, 21, a farmer in Agaku,Guinea-Bissau Nigeria, 79.1 in the field with the community pit latrine. WaterAidMozambique plans 79.5 to work in this area with the support of the HSBCGuinea Water 79.9 Programme. Burkina Faso 80.3 WaterAid/Andrew Esiebo Benin 80.3 Uganda 80.9

19 It’s No Joke: The State of the World’s Toilets 2015

Liberia 83.1 Eritrea 84.3 UnitedUrgent Republic of Tanzania action 84.4 is needed. Congo 85.0 Ghana 85.1 Sierra WhatLeone 86.7 should be done? Chad 87.9 Madagascar• Having 88.0 agreed the ambitious new Global Goals to end poverty by 2030, world Togo 88.4leaders must now step up to fund, implement and account for progress towards Niger 89.1the goals. Goal 6 – water, sanitation and hygiene for all – is fundamental to ending South Sudanhunger 93.3 and ensuring healthy lives for everyone, and must be a top priority. Mayotte no data • The state of the world’s toilets will not improve without a dramatic and long-term Somalia no data increase in financing for water, sanitation and hygiene by both national Sudan no data governments and donor countries like the UK. • To reduce maternal, newborn and child deaths, national governments must ensure that schools, health-care facilities and birthing centres have safe toilets, clean running water and functional sinks with soap for handwashing. • To make health and nutrition programming more effective, national governments should ensure that water, sanitation and hygiene services are embedded in plans to reduce undernutrition, acute malnutrition, childhood diseases and newborn deaths. • Many of the world’s poorest countries which are most in need of aid for sanitation and hygiene are neglected, because either the country or the sector does not fit with donors’ strategic priorities. Aid needs to be directed to where it’s needed most, at the levels required, and aligned with country systems and plans. • National governments also need to mobilise domestic revenue to make water, sanitation and hygiene a priority.

About WaterAid WaterAid’s vision is of a world where everyone everywhere has access to safe water and sanitation. The international organisation works in 37 countries across Africa, Asia, Central America and the Pacific Region to transform lives by improving access to safe water, hygiene and sanitation in some of the world’s poorest communities. Since 1981, WaterAid has reached 23 million people with safe water and, since 2004, 21 million people with sanitation. For more information, visit www.wateraid.org, follow @WaterAidUK on Twitter, or visit us on Facebook at www.facebook.com/wateraid. • Around 860 children die every day from diarrhoeal diseases caused by dirty water and poor sanitation. • Over 650 million people (around one in ten) are without safe water. • Over 2.3 billion people (around one in three) live without improved sanitation.

20 Appendix 1: Access to sanitation, Sub-Saharan Africa, highest to lowest

Appendix 1: Access to sanitation,64 Sub-Saharan Africa, highest to lowest65

Country % of population Country % of population without access without access

Seychelles 1.6 Democratic Republic of the Congo 71.3 Réunion 1.7 Ethiopia 72.0 Mauritius 6.8 Mali 75.3 Equatorial Guinea 25.5 Côte d’Ivoire 77.5 Cape Verde 27.8 Central African Republic 78.2 South Africa 33.6 Guinea-Bissau 79.1 Botswana 36.6 Mozambique 79.5 Rwanda 38.3 Guinea 79.9 Gambia 41.1 Burkina Faso 80.3 Swaziland 42.5 Benin 80.3 Angola 48.4 Uganda 80.9 Burundi 52.0 Liberia 83.1 Senegal 52.4 Eritrea 84.3 Djibouti 52.6 United Republic of Tanzania 84.4 Cameroon 54.2 Congo 85.0 Zambia 56.1 Ghana 85.1 Gabon 58.1 Malawi 59.0 Sierra Leone 86.7 Mauritania 60.0 Chad 87.9 Zimbabwe 63.2 Madagascar 88.0 Comoros 64.2 Togo 88.4 São Tomé and Príncipe 65.3 Niger 89.1 Namibia 65.6 South Sudan 93.3 Lesotho 69.7 Mayotte no data Kenya 69.9 Somalia no data Nigeria 71.0 Sudan no data

21 It’s No Joke: The State of the World’s Toilets 2015

Appendix 2: World access to sanitation,66 highest to lowest, 201567

Country % of population Country % of population without access without access

Andorra 0 Réunion 1.7 Australia 0 Norway 1.9 Austria 0 Qatar 2.0 Cyprus 0 Grenada 2.0 Greenland 0 Hungary 2.0 Israel 0 Maldives 2.0 Japan 0 Anguilla 2.1 Kuwait 0 Netherlands 2.3 Malta 0 Aruba 2.3 Monaco 0 Finland 2.3 New Caledonia 0 Cook Islands 2.4 Niue 0 Luxembourg 2.4 Palau 0 United Arab Emirates 2.4 Republic of Korea 0 Kazakhstan 2.4 Saudi Arabia 0 British Virgin Islands 2.5 Singapore 0 Estonia 2.8 Uzbekistan 0 Poland 2.8 United States of America 0 Croatia 3.0 Switzerland 0.1 Oman 3.2 Spain 0.1 Libyan Arab Jamahiriya 3.4 Canada 0.2 Uruguay 3.6 Portugal 0.3 Serbia 3.6 Denmark 0.4 United States Virgin Islands 3.6 Italy 0.4 Argentina 3.6 Belgium 0.5 Barbados 3.8 Sweden 0.7 Malaysia 4.0 Puerto Rico 0.7 Ukraine 4.1 Germany 0.8 Montenegro 4.1 United Kingdom 0.8 Syrian Arab Republic 4.3 Bahrain 0.8 Cayman Islands 4.4 Czech Republic 0.9 Sri Lanka 4.9 Slovenia 0.9 Tajikistan 5.0 Chile 0.9 Turkey 5.1 Greece 1.0 Bosnia and Herzegovina 5.2 Slovakia 1.1 Egypt 5.3 Iceland 1.2 Costa Rica 5.5 France 1.3 Venezuela (Bolivarian Republic of) 5.5 Jordan 1.4 Belarus 5.7 French Polynesia 1.5 Kyrgyzstan 6.7 Seychelles 1.6 Albania 6.8

22 Appendix 2: World access to sanitation, highest to lowest, 2015

Country % of population Country % of population without access without access

Cuba 6.8 Peru 23.8 Mauritius 6.8 Panama 25.0 Thailand 7.0 El Salvador 25.0 Lithuania 7.6 Equatorial Guinea 25.5 Occupied Palestinian Territories 7.7 Philippines 26.1 Bahamas 8.0 Russian Federation 27.8 Tunisia 8.4 Cape Verde 27.8 Trinidad and Tobago 8.5 Lao People’s Democratic Republic 29.1 Samoa 8.5 Nicaragua 32.1 Fiji 8.9 South Africa 33.6 Tonga 9.0 Nauru 34.4 TFYR Macedonia 9.1 Guatemala 36.1 Saint Lucia 9.4 Pakistan 36.5 Belize 9.5 Botswana 36.6 Ireland 9.5 American Samoa 37.5 Tokelau 9.5 Rwanda 38.3 Iran (Islamic Republic of) 10.0 Indonesia 39.2 Guam 10.2 Bangladesh 39.4 Armenia 10.5 Mongolia 40.3 Azerbaijan 10.7 Gambia 41.1 Paraguay 11.4 Vanuatu 42.0 Latvia 12.2 Swaziland 42.5 Algeria 12.4 Micronesia (Fed. States of) 42.9 Georgia 13.7 Angola 48.4 Bulgaria 14.0 Bhutan 49.6 Iraq 14.4 Bolivia (Plurinational State of) 49.7 Mexico 14.8 Burundi 52.0 Ecuador 15.3 Senegal 52.4 Dominican Republic 16.0 Djibouti 52.6 Guyana 16.3 Cameroon 54.2 Brazil 17.2 Nepal 54.2 Honduras 17.3 Zambia 56.1 Democratic People’s Cambodia 57.6 Republic of Korea 18.1 Gabon 58.1 Jamaica 18.2 Malawi 59.0 Colombia 18.9 Timor-Leste 59.4 Lebanon 19.3 Mauritania 60.0 Northern Mariana Islands 20.3 Kiribati 60.3 Myanmar 20.4 India 60.4 Suriname 20.8 Zimbabwe 63.2 Romania 20.9 Comoros 64.2 Viet Nam 22.0 São Tomé and Príncipe 65.3 Marshall Islands 23.1 Namibia 65.6 Morocco 23.3 Afghanistan 68.1 China 23.5 Lesotho 69.7 Republic of Moldova 23.6 Kenya 69.9

23 It’s No Joke: The State of the World’s Toilets 2015

Country % of population Country % of population without access without access

Solomon Islands 70.2 Brunei Darussalam No data Nigeria 71.0 Channel Islands No data Democratic Republic of the Congo 71.3 China, Hong Kong SAR No data Ethiopia 72.0 China, Macao SAR No data Haiti 72.4 Dominica No data Mali 75.3 Faeroe Islands No data Côte d’Ivoire 77.5 Falkland Islands (Malvinas) No data Central African Republic 78.2 French Guiana No data Guinea-Bissau 79.1 Mozambique 79.5 Guadeloupe No data Guinea 79.9 Isle of Man No data Burkina Faso 80.3 Liechtenstein No data Benin 80.3 Martinique No data Uganda 80.9 Mayotte No data Papua New Guinea 81.1 Montserrat No data Liberia 83.1 Netherlands Antilles No data Eritrea 84.3 New Zealand No data United Republic of Tanzania 84.4 Saint Kitts and Nevis No data Congo 85.0 Saint Vincent and the Grenadines No data Ghana 85.1 San Marino No data Sierra Leone 86.7 Somalia No data Chad 87.9 Sudan No data Madagascar 88.0 Turkmenistan No data Togo 88.4 Niger 89.1 Turks and Caicos Islands No data South Sudan 93.3 Tuvalu No data Antigua and Barbuda No data Western Sahara No data Bermuda No data Yemen No data

Maryam Terkuma, 28, by her family toilet in Oryua Nyam, Nigeria. WaterAid has worked with partners to deliver a water point and latrines with the support of the HSBC Water Programme. WaterAid/Andrew Esiebo

24 References

11 wateraid.org, taken from the Unicef-World Health Organization 32 http://apps.who.int/gho/data/view.main.ghe100-IND?lang=en Joint Monitoring Programme on Water Supply and Sanitation, 33 UNICEF-WHO Joint Monitoring Programme on Water Supply and 2015, wssinfo.org Sanitation, 2015, wssinfo.org 12 http://www.who.int/mediacentre/factsheets/fs178/en/ 34 http://data.worldbank.org/indicator/AG.SRF.TOTL.K2 13 Prüss-Ustün A, Bartram J, ClasenT et al (2014), Burden of disease 35 http://riceinstitute.org/maps/worldwide-density-of-open- from inadequate water, sanitation and hygiene in low- and defecation-by-country/ middle-income settings: a retrospective analysis of data from 145 36 http://data.worldbank.org/indicator/SP.DYN.LE00.IN countries, Tropical Medicine and International Health, 37 http:// data.worldbank.org/indicator/SH.STA.MMRT with http://www.ncbi.nlm.nih.gov/pubmed/24779548 calculations by region from: 14 http://blog.washwatch.org/2015/10/why-has-the-number-of- http://www.thelancet.com/pdfs/journals/langlo/PIIS2214- children-dying-from-diarrhoeal-disease-due-to-poor-wash-signific 109X(14)70227-X.pdf antly-dropped/ 38 http://www.WASHWatch.org 15 UNICEF, 2000. 39 http://www.countdown2015mnch.org/country-profiles 16 UN Water, 40 UNICEF-WHO Joint Monitoring Programme on Water Supply and http://esa.un.org/iys/docs/IYS%20Advocacy%20kit%20ENGLISH Sanitation, 2015, wssinfo.org /Fact%20sheet%201.pdf 41 UNICEF-WHO Joint Monitoring Programme on Water Supply and 17 http://www.who.int/mediacentre/factsheets/fs348/en/ Sanitation, 2015, wssinfo.org 18 http://www.thelancet.com/journals/langlo/article/PIIS2214- 42 http://data.worldbank.org/indicator/NY.GNP.PCAP.CD/ 109X(14)70227-X/fulltext countries?display=default 19 http://www.who.int/water_sanitation_health/publications/wash- 43 http://data.worldbank.org/indicator/SP.DYN.LE00.IN health-care-facilities/en/ 44 http:// data.worldbank.org/indicator/SH.STA.MMRT with 10 http://www.wateraid.org/~/media/Publications/Healthy- calculations by region from: Start.pdf?la=en http://www.thelancet.com/pdfs/journals/langlo/PIIS2214- 11 http://blog.washwatch.org/2015/10/why-has-the-number-of- 109X(14)70227-X.pdf children-dying-from-diarrhoeal-disease-due-to-poor-wash-signific 45 http://www.WASHWatch.org antly-dropped/ 46 UNICEF-WHO Joint Monitoring Programme on Water Supply and 12 http://www.unicef.org/wash/schools/files/Advancing_WASH_ Sanitation, 2015, wssinfo.org in_Schools_Monitoring(1).pdf 47 https://spdb.ohchr.org/hrdb/24th/Canada_25.07.13_ 13 WHO, Global costs and benefits of drinking-water supply and (3.2013)_response.pdf sanitation interventions to reach the MDG target and universal 48 UNICEF-WHO Joint Monitoring Programme on Water Supply and coverage, 2012 Sanitation, 1990 and 2015, wssinfo.org http://apps.who.int/iris/bitstream/10665/75140/1/WHO_HSE_ 49 UNICEF-WHO Joint Monitoring Programme on Water Supply and WSH_12.01_eng.pdf?ua=1 Sanitation, 1990, wssinfo.org 14 http://www.oecd.org/dac/stats/documentupload/ODA%20 50 UNICEF-WHO Joint Monitoring Programme on Water Supply and 2014%20Technical%20Note.pdf Sanitation, 2015, wssinfo.org 15 http://www.copenhagenconsensus.com/publication/post-2015- 51 http://data.worldbank.org/indicator/NY.GNP.PCAP.CD/ consensus-water-and-sanitation-assessment-hutton countries?display=default 16 UNICEF-WHO Joint Monitoring Programme on Water Supply and 52 http://data.worldbank.org/indicator/SP.DYN.LE00.IN Sanitation, 2015, wssinfo.org 53 17 http:// data.worldbank.org/indicator/SH.STA.MMRT with http://data.worldbank.org/indicator/NY.GNP.PCAP.CD/ calculations by region from: countries?display=default. http://www.thelancet.com/pdfs/journals/langlo/PIIS2214- 18 http://data.worldbank.org/indicator/SP.DYN.LE00.IN 109X(14)70227-X.pdf 19 http:// data.worldbank.org/indicator/SH.STA.MMRT with 54 http://www.WASHWatch.org calculations by region from: 55 http://www.countdown2015mnch.org/country-profiles http://www.thelancet.com/pdfs/journals/langlo/PIIS2214- 56 UNICEF-WHO Joint Monitoring Programme on Water Supply and 109X(14)70227-X.pdf Sanitation, 1990 and 2015, wssinfo.org 20 http://www.WASHWatch.org 57 UNICEF-WHO Joint Monitoring Programme on Water Supply and 21 http://www.countdown2015mnch.org/country-profiles Sanitation, 2015, wssinfo.org 22 http://data.worldbank.org/country/south-sudan 58 UNICEF-WHO Joint Monitoring Programme on Water Supply and 23 World Bank, 2009 data, Sanitation, 1990, wssinfo.org http://data.worldbank.org/country/south-sudan 59 http://data.worldbank.org/indicator/NY.GNP.PCAP.CD/ 24 http://wssinfo.org countries?display=default 25 World Bank, 2010 data, 60 http://data.worldbank.org/indicator/SP.DYN.LE00.IN http://data.worldbank.org/country/madagascar 61 http:// data.worldbank.org/indicator/SH.STA.MMRT with 26 Unicef-WHO Joint Monitoring Programme on Water Supply and calculations by region from: Sanitation, 2015, wssinfo.org http://www.thelancet.com/pdfs/journals/langlo/PIIS2214- 27 http://data.worldbank.org/indicator/NY.GNP.PCAP.CD/ 109X(14)70227-X.pdf countries?display=default 62 http://www.WASHWatch.org 28 http://data.worldbank.org/indicator/SP.DYN.LE00.IN 63 http://www.countdown2015mnch.org/country-profiles 29 http:// data.worldbank.org/indicator/SH.STA.MMRT with 64 http://www.wssinfo.org/definitions-methods/watsan-ladder/ calculations by region from: 65 UNICEF – World Health Organization Joint Monitoring Programme http://www.thelancet.com/pdfs/journals/langlo/PIIS2214- on Water Supply and Sanitation, 2015, wssinfo.org 109X(14)70227-X.pdf 66 http://www.wssinfo.org/definitions-methods/watsan-ladder/ 30 http://www.WASHWatch.org 67 UNICEF – World Health Organization Joint Monitoring Programme 31 http://www.countdown2015mnch.org/country-profiles on Water Supply and Sanitation, 2015, wssinfo.org Written by: Carolynne Wheeler with support from Fiona Callister, Andrés Hueso, Elisa Dehove, Dan Jones, Fleur Anderson, Rebecca Heald, Megan Wilson-Jones, WaterAid India, WaterAid Nigeria, WaterAid Nepal, WaterAid Niger.

Front cover: Women queuing for the toilet. Juhi Bamburahiya, Kanpur, Uttar Pradesh, India. November 2015 www.wateraid.org #StateofToilets #ItsNoJoke

Global/UK: Fiona Callister, [email protected]; or Carolynne Wheeler, [email protected]; or [email protected]

USA: Alanna Imbach, [email protected]

Canada: Graham Milner, [email protected]

Australia: Kirrily Johns, [email protected]

Sweden: Magdalena Olsson, [email protected] or Petter Gustafsson, [email protected]

WaterAid is a registered charity: Australia: ABN 99 700 687 141. Canada: 119288934 RR0001. Sweden: Org.nr: 802426-1268, PG: 90 01 62-9, BG: 900-1629. UK: 288701 (England and Wales) and SC039479 (Scotland). US: WaterAid America is a 501(c) (3) non-profit organization.